Parent(s) or Guardian with whom the child resides:* This field is required.

Name

Address

City, Zip Code

Home phone

Cell Phone (if applicable)

Place of Employment

Work Phone

YES

NO

Is this student(s) in Foster Care

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9

Emergency Contacts* This field is required.List 2 alternates for us to contact in the event that the parents cannot be notified. A minimum of 1 person other than parent/guardian is required.

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10

Doctor, Phone, Hospital

Doctor

Phone

Hospital

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11

Any medical conditions/allergies the staff should be aware of:

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12

Symptoms:

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13

Medication:(Note: Hoosier Uplands staff are not allowed to administer medications of any kind.)

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14

Medical assistance should be contacted immediately if:

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15

Comments:

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16

Your child must be signed out from the Afterschool Program by a guardian or person listed below. Please list below the other persons authorized to pick up your child. The Hoosier Uplands staff must be notified in writing of any changes. The first two people listed will be contacted in the case of an emergency, if parent cannot be reached. * This field is required.

Name of Contact

Relationship to student:

Phone:

Contact 1

Contact 2

Contact 3

Contact 1

Contact 2

Contact 3

Name of Contact

Relationship to student:

Phone:

Name of Contact

Relationship to student:

Phone:

Name of Contact

Relationship to student:

Phone:

1 of 3

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17

Transportation

YES

NO

Will Transportation on the bus to your home at 5:00 P.M. be needed? (Transportation is limited and not guaranteed)

Directions to your home:

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18

Consent to Share Information* This field is required.Signing this form permits Shoals Elementary School to share confidential information and work together in providing services for students that are enrolled in the 21st Century Community Learning Centers Program. I authorize the school to exchange information relating to the above named student. This agreement will expire on June 30, 2021. This information will be used to develop educational profiles of your child/children. I understand that personal records are protected by various federal and state laws and cannot be disclosed without this, my written consent, unless otherwise authorized.

YESNO

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19

For All Participants

I agree to give Hoosier Uplands permission to photograph my child. These photos may be used in support of the program as needed.

I agree to inform my child/children of the policies of this program and will insist that they abide by them while participating in the program.

I agree to give Hoosier Uplands permission to access and keep copies of my child’s academic records, including report cards, standardized test scores and cumulative records. This permission will extend throughout the school year. These scores will be kept confidential and only be used by Hoosier Uplands and Indiana Department of Education.

Hoosier Uplands is not responsible for lost or stolen items such as mp3 players, cell phones, etc.

I understand that priority will be given to students with academic need, working parents, and free/reduce lunch status; however, any student that is enrolled in Shoals Elementary School is able to apply for the program.

I agree that students that are accepted in to the program will be required to attend at least 3 days per week and stay until 4:15 P.M.

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20

I agree with all of the above:

Name

Date

Relationship to Student

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21

Signature of Parent/Guardian* This field is required.

Clear

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Should be Empty:

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